Mental Health: Dual Diagnosis and Effective Treatment

The comorbid existence of a mental illness and a substance abuse problem is called “dual diagnosis.” Until recently, I hadn’t read or heard too much about it, beyond its basic definition, but was interested to learn that the condition brings about its own set of treatment considerations. Today, Matthew Peters is here to share his personal experience and insights with regard to dual diagnosis. I’m grateful for both his courage and willingness, because sharing our stories is the fastest path to reducing stigma and shame. I hope you’ll join in the conversation by leaving a comment below.

Dual Diagnosis Guest Post by Matthew Peters

My deepest thanks to Laura Zera for having me as a guest on her blog to share my experience with dual diagnosis. It is truly an honor to be here.

There are some variations in definitions of dual diagnosis, but the term generally describes a person who has a mood disorder and some form of chemical dependency. For example, I have depression (Major Depressive Disorder) and I’m an alcoholic. There are genetic links associated with each disorder. My mom was an alcoholic and suffered from depression and generalized anxiety disorder. There was a long line of depression and alcoholism on her side of the family: her father was an alcoholic and committed suicide when she was ten.

I drank regularly by the time I was thirteen. I sought help at a local substance abuse clinic when I was fifteen. Despite being dual diagnosed from an early age, the diagnosis didn’t stick. Over the years, as I made my way through countless detoxes and rehabs, and a few psychiatric wards, the standard course of treatment was to deal with one disorder without addressing the other, or the combined effect of both. It was more than twenty years before I received the help I needed.

The most effective treatment program I’ve found is the cognitive behavioral therapy approach used by places such as ASAP (Alcohol and Substance Abuse Program) in Chapel Hill, North Carolina. ASAP takes a comprehensive approach to substance abuse that involves education and group therapy as well as one-on-one sessions with therapists. Crucially, there is a strong psychiatric component built into the program because of the recognition that mental illness and substance abuse are often comorbid. I feel that recovery is limited for the dual-diagnosed unless both conditions are treated concurrently.

In terms of recovery, having a dual diagnosis differs from a single diagnosis in that it is not just about refraining from alcohol, or taking anti-depressants. It is a synergistic condition where one illness exacerbates the other. For example, major bouts of depression are often accompanied by the desire to self-medicate. It might sound counter-intuitive to want to drink alcohol, which is a depressant, when you are depressed, but the mind and brain chemistry of the alcoholic differ from that of the non-alcoholic. Drinking may actually alleviate depression in the short-term, lifting your spirits, so to speak, and quickly, too. That makes drinking very enticing to a person going through a depressive episode; the solution to feeling bad seems just an arm’s length away. Of course, what happens is that you might feel better after taking a few drinks, but when the effect wears off you are at a lower mood baseline than before you drank.

The thing I would change about the way dual diagnose is treated today is that in the presence of one of these conditions, an aggressive effort be made to determine whether the other is present. I would also often make it so that in regard to treating substance use disorder, Twelve Step Programs (TSPs) such as Alcoholics Anonymous are not the sole recourse. There needs to be a much more comprehensive method of treating dual diagnosis, one that allows a large role for education and cognitive behavioral therapy, and is inclusive with regard to people with little or no faith in a higher power. TSPs, in their Higher Power-based philosophy, often deter the latter. Also, when it comes to the dual-diagnosed, especially those who need medication to treat their condition, I would proceed with great caution when it comes to Twelve Step Programs (TSPs). Some groups tend to be anti-medication, and some people really need to be on medicine to help control their mental health symptoms.

Fortunately, dual diagnosis has not gotten in the way of achieving my goals, though it did play a large part in how things have played out in my life. But right now I couldn’t be happier. Though I dropped out of high school, I went on to get my B.A., M.A., and Ph.D. I taught college for a while, and now I write full-time. The point is that there is treatment out there if you are willing. You need to be your own best advocate when it comes to getting well and keeping the symptoms of dual diagnosis from taking control of your life. My journey has not been a linear progression, where over time I have gotten better and better. At times it has been a “one step forward, two steps back” process, and I think acknowledging that is crucial in going forward and getting on with your life.

My website, www.matthewpetersbooks.com, includes resources for helping those dealing with dual diagnosis and related issues. My blog also discusses my own experiences with dual diagnosis. Since writing has been a crucial part of my recovery, I also talk a lot about writing. I encourage you to come by and check it out. Always remember that however low you feel, there is help out there.

Here are some interesting facts about dual diagnosis and related issues from a book called Addiction and Mood Disorders: A Guide for Clients and Families, by Dennis C. Daley, with Antoine Douaihy (Oxford University Press, 2006). I highly recommend the book for anyone interested in the subject of dual diagnosis.

“Mood disorders are higher among people with alcohol and drug dependence than among the general population. For example, the risk of having a substance abuse disorder is four times higher if you have depression and up to 14 times higher if you have a bipolar disorder.” (pp. 8-9)

“Over 16% of adults in the United States will have a problem with alcohol or drug abuse or dependence at some point in their lives.” (p. 18)

“Depressive disorders affect about 20% of women and 12% of men at some time in their lives, and bipolar disorders affect a little more than 1% of the population, with men and women being affected equally.” (p. 40)

“Almost 1 out of 3 people with depressive disorders will also have problems with alcohol or drug abuse or dependence. About 1 in 10 people with major depression will also experience a bipolar disorder. Others will have an anxiety, eating, or personality disorder. Hence, people with clinical depression often have other psychiatric or substance abuse disorders as well.” (pp. 42-43)

“Up to 60% of people with bipolar illness also have a problem with alcohol and drug abuse or dependency.” (p. 47)

About Matthew Peters

Dual diagnosed from an early age, Matthew Peters dropped out of high school at sixteen. He went on to obtain a B.A. from Vassar College, and an M.A. and Ph.D. from Duke University. He has taught various courses in a variety of disciplines throughout North Carolina.

Matthew is committed to increasing the awareness and understanding of the dual-diagnosed. Conversations Among Ruins (forthcoming through All Things That Matter Press) is his first novel, and includes a dual-diagnosed character. His second novel, The Brothers’ Keepers (forthcoming through MuseItUp Publishing in summer/fall 2014), is a political-religious thriller that capitalizes on his love for history and research. Currently, he is working on a sequel to The Brothers’ Keepers. Learn more at http://matthewpetersbooks, or follow Matt on Twitter.

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Comments

I have to say in reading your blog post that I’m a little floored at the lack of understanding regarding dual diagnosis from the ‘professionals.’

As a therapists, I would never look at a client and think ‘alcoholic’ – they ‘just have’ an addiction problem. I would always assume there’s some underlying cause pertaining to the addiction. Always.

As always, things like this exhaust me on some levels. Not because of the people who are diagnosed with any level of brain chemistry issue. But because there are too many people who are not treated properly. I have a lot of issues with the 12 step programs. Yes, and before you all get stuck into me. I KNOW they do good. However, they invariably don’t address the underlying issues. And that always bothers me a lot. They’re like the band aid solution. People don’t drink or gamble or any other addiction because they’re happy… Something’s wrong.

I’m actually sitting here at a slight loss for words. As you know Matt… not like me 🙂 I’m floored that anyone as a therapist or in a therapy situation would not instantly look at the brain chemistry and other issues going on with someone. It’s pretty basic.

Then I get angry at how much people suffer, often for years, because nobody thinks to think. Or put something fundamental together in looking holistically at a person. I am constantly appalled at the level of non care with the allopathic community on every level. This is just another example of health ‘care’ people who don’t.

It took me a long time to work out what was happening with my own brain chemistry. But really… over the years, there had to have been someone out there better trained than I am now that could have worked it out.

Thanks for sharing Matt. You’re an amazing person who does amazing things!

Yes, unfortunately, dual diagnosis is not identified and treated as often as it should or could be. I think you are so right about there being underlying problems involved: people drink or gamble (or whatever their addiction of choice) for a reason, and often that reason has to do with underlying emotional disorders.

I think Twelve Step Programs, like Alcoholics Anonymous, can do more harm than good, when it comes to people who are dual-diagnosed and need to be on medication to treat their symptoms. Some people in AA are anti-medication and actually discourage people from taking prescribed meds. This is tantamount to practicing medicine without a license, and needs to stop.

We need a more aggressive approach to diagnosing and treating both disorders. The “success rate” of Twelve Step Programs, such as Alcoholics Anonymous, is abysmal, and it’s time that is recognized. Much more effective treatment seems to come in the form of cognitive behavioral therapy that is conducted by LICENSED PROFESSIONALS, people who are equipped to detect comorbidity if and when it is present.

Shalom, Meg and Matt! (Just trying to throw you off.) Meg, I could feel your frustration through my computer monitor! I wonder if “one-sided” treatment and lack of dual diagnoses is sometimes a result of people who have a substance abuse issue going straight to AA or a Twelve Step program because not even they detect that they might have a mental illness, as well. A substance abuse program may be where they start, and where they stay. So what kind of retooling can be done with those programs, hey? Hmmmm. Something that facilitate the engagement of a licensed mental health professional in the substance abuse programs’ setting.

Just want to add my two cents. I think 12 steps can get to the underlining problems. But it depends on the groups and the level of the people that you are with. But what I found is that there is extremes every where you go. So for example you can get addicted to 12 step groups etc. And then, judge other for not doing whatever you think is right. Loads of judgment. But then again, let’s face it, judgment is everywhere. Just one more rut to get in. 🙂Jodi from Heal Now and Forever recently posted…The best breathing technique for a panic attack

If I understand you correctly, Jodi, you’re saying that some 12 Step groups (or similar groups) could have members who are skilled and knowledgeable enough to ask questions of each other that will flesh out the mental illness components of people’s conditions.

To your comment about extremes, and to what Matthew has said about the faith-based nature of some of these groups then promoting non-use of medication, I bet that a 12 Step group in San Francisco could have a whole different outlook than one in Little Rock. I just picked those two cities off the top of my head, but I’m trying to say that even geography could create extremes in a group’s characteristics.

“Sharing our stories is the fastest path to reducing stigma and shame” – spot on, Laura – and huge thanks to you both for doing so here with this post. I hadn’t been aware of dual diagnosis as an issue before but having read Matthew’s crystal-clear, calm explanation, it makes perfect sense. I hope have read this will make me better able to recognise and support anyone I know who is in the same situation. A brave and compelling post.Debbie Young recently posted…Hung Up On Laundry

Thank you so much for stopping by and commenting, Debbie. It is such a pleasure to be able to share on the topic, especially since dual-diagnosis is not in the vernacular. Thanks to Laura for the opportunity to do so, and thanks to people like yourself who are interested in learning about and supporting others who face such a situation.Matthew Peters recently posted…Guest Post on Dual Diagnosis

Thanks to both of you Matthew and Laura. I have no experience with either of these topics but I’m always fascinated by how people think and why people do what they do. This is similar. I am very glad to hear that there is a way thought it all and not at all surprised to hear how it is all connected. Thank you for clarifying this condition while offering hope for those who seek it. !Kathy

Thank you , Kathy. I’m always glad when someone who is not familiar with the condition becomes familiar with it. That is what it’s all about. And yes, there is a way through it all. That is perhaps the best part of the message, that it doesn’t have to be a permanent debilitating condition. There is treatment out there. And there is hope. I would encourage anyone interested in the treatment aspect to check out the approach of ASAP in Chapel Hill, North Carolina as a model for what is possible in the treatment of dual diagnosis.Matthew Peters recently posted…Guest Post on Dual Diagnosis

Thanks for the post Laura and Matthew. What you’ve shared about dual diagnosis makes complete sense, yet as you state above, it’s not really in the vernacular. I like how you point out that recovery isn’t linear. Too often that gets overlooked. Given that mental illness and/or alcoholism runs rampant in my family, I have do doubt a dual diagnosis would apply to more than a few of them, but they don’t even seek help for one let alone both issues. Yeah, that’s my “happy” gene pool…Jeri recently posted…#AuthorInterview: Melissa Reyes

Thanks for stopping by and commenting, Jeri. It is very difficult to watch family and friends in the grips of an emotional disorder and chemical addiction. I didn’t realize just how difficult until I got effective treatment. And you raise an important point, Jeri. Both disorders are (at least) in part genetic. It would be interesting to see data that deal with the genetics of dual diagnosis, though I am not aware of any off the top of my head.Matthew Peters recently posted…Guest Post on Dual Diagnosis

Definitely a genetic component, just hard to isolate that from the socio-environmental components. But the genetics are like the kick-off to the perfect storm. Sorry that these issues are affecting even more of your family than your mom, Jeri.

Mathew, you write with such clarity and lucidity about a topic that is anything but. My impression is that not all therapists are trained to make dual diagnoses. It’s like the saying if the only tool you have is a hammer, then all problems look like nails.

Isn’t there also a concern about mis-diagnosis when comorbidy is present? I know of a case in which a therapist identified both alcoholism and a mental illness but had trouble specifying the mental illness. The girl in question was diagnosed (by additional therapists) as bi-polar, schizophrenic and depressed. Finally, one of them suggested she deal with the alcoholism first. Once in recovery, depression and anxiety disorders emerged more clearly.

You raise a crucial issue: the difficulty of diagnosing a mental illness when a person is in the active throes of addiction. Since addiction can often mimic the symptoms of a mental illness it can be difficult to accurately diagnose a comorbid mood disorder.

What we do know is that mental illness if often hereditary. One of the issues that needs to be determined is whether a person who is presenting signs of addiction also has an underlying mood disorder. Consequently, one of the first lines of defense in treating addiction should be finding whether a mental illness runs in the family of the client, rather than simply determining that the client, as an addict, suffers from a spiritual malady, and needs a spiritual-based “solution” like that found in Alcoholics Anonymous. In some ways, I feel existing approaches put the wagon of addiction before the horse of mental illness, and I think this needs to be changed.

Clients who are told to get sober before dealing with a possible mental illness risk never getting sober and thus never getting treatment for a comorbid mood disorder. I know in my case I couldn’t get and stay sober until my depression was aggressively treated. This is my fear concerning the wait-and-see approach, though it is certainly understandable given the fact that addiction and mood disorders often present similar symptoms.

Also, I’m thinking that in the absence of a family history of mental illness, that an attempt to get a clear understanding of whether the person had symptoms of a mental illness before they started using a chemical substance would be important. And/or maybe that should be done with every substance abuse treatment protocol. Thanks, Jagoda and Matt, that’s a compelling dilemma that you’ve both tackled here.

Thanks for sharing your story Matthew. I wasn’t very aware of dual diagnosis or how it should be treated. I knew that there was sometimes a link between substance abuse and mental health illnesses and it is true that one can feed the other. What you are left with is a vicious cycle and they are always incredibly difficult to break out of. Do you think enough people know about dual diagnosis? Does more need to be done to educate people? I wonder if all professionals know that the most effective way of treating dual diagnosis is by addressing both the problems simultaneously.

Thanks for commenting, Elena. I don’t think all health professionals are aware of how best to treat dual diagnosis. Unfortunately, the problems of diagnosing/treating the dual diagnosed is exacerbated by insurance policies, which are set up to treat every ailment as a separate condition. It is estimated that 6 out of 100 Americans suffer from a dual diagnosis. One can only hope the situation is viewed more holistically in the near future.Matthew Peters recently posted…Giving Yourself Permission to Write

Matthew, I’d never even thought of the insurance conundrum that could come into play. They are so whacky about how claims are submitted, what codes are used, etc. Insurance frameworks are also affecting how psychiatrists work with patients, e.g., dispense meds instead of having time to talk.

Thank you Matthew and Laura. I was completely unaware of the weight of the insurance policies and I cannot believe it. I’m shocked by this and that the health of the people isn’t put first. It frustrates me that there are a ridiculously high amount of people who suffer from one or the other or both and yet progress seems to be slow. I think the bottom line is that people don’t talk about it. It is why things such as dual diagnosis are a mystery.

I think you are absolutely correct, Elena. Part of the reason I believe it’s not talked about more often is the double stigma attached to dual diagnosis. Mental illness still carries with it a stigma, and certainly addiction does as well. Put the two together and it creates a situation that is extremely difficult to talk about without people bringing preconceived notions to the table.Matthew Peters recently posted…Writing: It’s What’s for Dinner